Constipation and Diarrhoea

7/28/2019 Constipation and Diarrhoea

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Gastro-intestinal problems are common in children. Most are self limiting and clear

up without incident. However, they can be serious in some children and may mask

underlying disease. This chapter looks at two of the most common problems

constipation and diarrhoea and the role pharmacists can play in their treatment.

Objectives

On completion of this chapter you will

be familiar with the likely causes of constipation and diarrhoea

know the best way to resolve such problems

learn about features that may suggest a more serious

underlying illness.


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Constipation and diarrhoea

1. Constipation

Constipation is defined as difficulty or delays in passing a stool. By four years of age, a child will

normally have one bowel motion a day. Constipation is present if a child aged over four passes

fewer than three stools per week or has pain upon defecation, coupled with stool retention.

It is an extremely common condition in paediatric medicine and can affect up to 8% of children.

More boys are affected than girls. The reasons for this are unclear but the majority of cases of

constipation are likely to be due to lifestyle, including lack of fluid intake, inappropriate diet and

behaviour patterns. Other less common reasons include allergy to cows milk, Hirschsprungs

disease and the side effects of medicine such as opiates and anticholinergic agents.

Some constipated children have very infrequent passage of stools, which can lead to a mega

colon, impaction and encopresis. Encopresis is the leakage of liquid or soft stool which flows

around impacted faeces and results in soiling.

Many health professionals do not approach the treatment of childhood constipation in a

structured and logical way. This can lead to chronic problems that may not be resolved for years.

The role of the pharmacistThe influence a pharmacist can have on the treatment of childhood constipation depends on a

number of factors. These include the experience, knowledge, enthusiasm and seniority of the

individual pharmacist and, for hospital pharmacists, the type of hospital that he or she works in.

One of the most important elements of the pharmacists job is to raise awareness of new products

and disseminate information about the condition and how it should be treated.

Most specialist childrens hospitals have constipation resource packs for use by health

professionals. A pharmacist in such a hospital should be familiar with the local guidelines and

ensure that they are adhered to. It is important that new junior doctors are made aware of such

guidelines. In these situations, the pharmacist is ideally placed to influence and educate all staff.

In some general hospitals, pharmacists have developed these resource packs for other health

professionals, as well as becoming involved in bowel management clinics, and counselling of

young patients and their carers or parents.

Many laxative drugs are available for children over the counter. However the use of these drugs in

children should be discouraged, unless prescribed by a doctor. Community pharmacists should,

however, provide information on side effects and appropriate administration of the prescribed

medicine.

Education and behaviour therapyMost of the children seen in hospital bowel management clinics have had chronic constipation

for months or years. The good news is that the majority of these children will be problem free

within 12 months. There is no quick fix for long-term childhood constipation. It is best not to

be dogmatic in the choice of laxatives or doses or in the form of help to be offered. A flexible

approach is required that includes detailed explanations and the use of behavioural therapy.

The staged approachThe medicines given may have been used by the patient previously but a multi-disciplinary and

sustained approach will produce results.

The staged approach consists of:

stool softeningclearing out impacted faeces

maintaining normal bowel function.


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Introduction to paediatric pharmaceutical care

1.1 Stool softening

An increase in fibre and fluid is one of the first lifestyle changes that should be recommended.

Children should be encouraged to drink plenty of water with all meals, as well as apple juiceor prune juice. More fruit and vegetables should be introduced but in a manner which avoids

confrontations at meal times.

Only two stool softeners are recommended for the majority of patients lactulose and

docusate.

LactuloseLactulose is metabolised in the gut to acetic and formic acids that promote bacterial growth

and increase faecal bulk and softness. Lactulose is described as a bulk forming osmotic laxative.

It should be taken with plenty of water.

It is pleasantly sweet tasting and suitable for long-term use. However, it takes at least 48 hours

to work. Lactulose should be used for 5-7 days to soften stool bulk before introducing clear out

medicines.

Doses of lactulose

Age


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1.2 Clear out medicines

As explained previously, a clear out medicine should be used following 5-7 days treatment with

a stool softener. In community pharmacy, Movicol-Half sachets or Picolax sachets are normally

used. In hospital, it may necessary to use Klean-Prep or enemas. A manual clearout may be

required for some seriously impacted children.

Movicol Paediatric PlainMovicol Paediatric Plain contains macrogol 3350 and electrolytes, and acts as an osmotic laxative.

The electrolytes are present to ensure that there is no net loss, or gain, of sodium or potassium.

Doses of Movicol Paediatric Plain (sachets per day)

Age 24 years 511 years

Dose day 1 2 4

day 2 4 6

day 3 4 8

day 4 6 10

day 5 6 12

The contents of each sachet should be dissolved in 62.5ml of water. The daily number of sachets

should be taken over a period of 12 hours. The above regime must be discontinued after

disimpaction has occurred.

Activity 6.2

A prescription for a three-year-old is written as Movicol 2

sachets daily. What would you do?

workbook page 13

Doses of docusate sodium

Age 1 month 2 years 212 years 1218 years

Dose 2.5mg/kg 2.5mg/kg 100mg

Times/day 3 3 3

Parents or carers may be told to increase or decrease the dose according to response. Docusate

can be given along with lactulose for children who have not responded to lactulose alone.


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PicolaxPicolax is a combination of sodium picosulphate and magnesium citrate, and is described as

a bowel cleaning solution. Its mode of action is a combination of a stimulant and an osmotic

laxative.

Doses of Picolax

Age 1-2 years 2-4 years 4-9 years over 9 years

Dose times/dayquarter sachet

twice a day

half sachet

twice a day

one sachet

morning and half

sachet afternoon

one sachet

twice a day

Patients should be prescribed 4-6 doses and the treatment discontinued after disimpaction has

occurred.

1.3 Other products

If the above products have failed to disimpact, the following alternatives can be tried.

Klean-PrepThe use of this product requires considerable co-operation from the child as a large volume must

be consumed to produce an effect.

Dosage of Klean-Prep is 25ml/kg every hour until rectal effluent is clear which can take

4-10 hours. In some cases the nasogastric route may have to be used.

Micralax EnemaChildren over three years of age may be given the total contents of one enema. The onset action is

15-30 minutes and treatment should be repeated after 24 hours if necessary.

Liquid paraffinThis product is useful if patients have not responded to other therapy. Do not give to children

under three years old.

The dose of liquid paraffin for 3-12 years old is 0.5-1ml/kg (max dose) and for 12-18 years old

10-30ml. This should be given once a day in the evening.

1.4 Maintenance medicine

Most patients require a combination of at least two maintenance medicines for a long period,

typically lactulose and senna for one year. Lactulose is covered above under stool softening.

Senna

Senna is a stimulant laxative and must not be given until a chronically constipated childs stools

have been softened. It takes 8-12 hours to have an effect and is therefore usually given once at

bedtime. Some children may benefit more from a morning dose of senna.

Doses of senna

Age 1 month-2 years 2-6 years 6-12 years 12-18 years

Dose (liquid) 0.5ml/kg 2.5-5ml 5-10ml 10-20ml

Dose (tablets) not recommended not recommended 1-2 2-4

Parents or carers may be told to increase or decrease the dose according to responses.


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2. Diarrhoea

Diarrhoea and other conditions such as vomiting and abdominal pain are common symptoms of

gastrointestinal disorder in childhood. In many instances, such illnesses are self limiting and resolve

rapidly without signifying serious underlying disease. However, some aspects of the clinical history

should raise concern and prompt medical referral.

Worrying pointers include:

chronicity of symptoms (persistence for more than two weeks)

associated weight loss or poor growth

poor sleeping/nocturnal waking

recurrent interruption of normal activities (e.g. missing school)

a family history of gastrointestinal illness with similar symptoms (e.g. pyloric stenosis , coeliacdisease, inflammatory bowel disease, peptic ulcers).

2.1 Acute diarrhoea

Diarrhoea can be defined as the frequent passage of watery stools. During short-lived episodes

of acute onset diarrhoea, the main risk to the child is dehydration and associated electrolyte

disturbance. Infants under six months are at greatest risk of dehydration because they have increased

insensible fluid losses and, when formula fed, receive a large osmotic and high renal solute load.

Causes

Acute sickness and diarrhoea is usually infectious in origin. The infecting organisms are:

viral this is the most common cause and includes rotavirus, adenovirus, Norwalk agent

bacterial such as salmonella, shigella, campylobacter, E. coli

protozoal (for example, Giardia lamblia).

Quite often, no pathogen can be isolated from stools in children admitted to hospital with diarrhoea.

It should be remembered that, in the young child, extra-intestinal sepsis might cause acute sickness

and diarrhoea.

Worrying features that should suggest a diagnosis other than acute, viral gastroenteritis include:

a generally unwell child

abdominal pain (possible surgical problem, e.g. appendicitis or intussusception )bloody stool (possible intussusception or haemolytic uraemic syndrome).

ManagementThe most important principle of management in the child with acute diarrhoea is prevention or

correction of dehydration with its associated electrolyte disturbance, together with maintenance or

resumption of adequate nutritional intake.

There is no role for anti-diarrhoeal drug therapy, such as loperamide, which simply masks underlying

fluid losses. Based on the discovery that glucose stimulates sodium transport in the small intestine,

glucose and electrolyte solutions (GESs) have become widely available. Substitutes such as home

made salt and sugar solutions are notoriously inaccurate. Popular soft drinks are hyperosmolar and

may provoke an osmotic diarrhoea.In Europe, GESs containing around 60 mmol/l of sodium are recommended (e.g. Dioralyte, or Dioralyte

Relief, which contains rice powder rather than glucose). Unfortunately, it is still often the case that children

admitted to hospital with gastroenteritis have not been offered GES while at home.


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Activity 6.3

Look at the rehydration solutions you have available in your

pharmacy. List the contents in 1000ml of solution when made up

as described and compare them.

workbook page 13

The majority of children can be treated safely in the community but there should be a lower

threshold for admission to hospital for infants under six months. Small amounts of fluid given

frequently are often tolerated, even when vomiting (from gastric stasis

) has been a prominentsymptom.

Activity 6.4

Jennifer, a two year old girl, has been unwell for two days with

diarrhoea. Her mum asks what you would advise for her as she

is now vomiting too. On questioning mum, you consider that

Jennifer has gastroenteritis and is at risk of dehydration. How

would you advise her?

workbook page 14

Maintenance fluid requirements are:

100ml/kg/day for the first 10kg body weight

+ 50ml/kg/day for the next 10kg body weight

+ 20ml/kg/day for remaining body weight.

These requirements should be supplemented if the child has frequent or substantial watery

stools, or vomits, by an additional 10ml/kg per stool/vomit.

Children with gastroenteritis do not need to be starved during the illness. Normal formula

feeds can be introduced following an initial four hour period of rehydration. Breast-feeding

should continue through rehydration and maintenance phases of treatment. In children

who are weaned, normal fluids and solids can be reintroduced after rehydration. If there is

persistent diarrhoea after reintroduction of feeds, lactose intolerance or cows milk protein

intolerance should be considered.


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Activity 6.5

List the symptoms of dehydration that you may see in an infant

or child.

workbook page 14

2.2 Chronic diarrhoea

Chronic diarrhoea, lasting more than two weeks, particularly if associated with weight loss,

needs hospital investigation. There is a long differential diagnosis which includes coeliac disease

(gluten sensitive enteropathy) and inflammatory bowel disease (i.e. Crohns disease, ulcerative

colitis). A family history of these conditions should increase diagnostic suspicion.

Toddler diarrhoea typically occurs in the second year of life and is associated with undigested

food such as peas and carrots in the stools. The child is well and growing normally. It is thought

to relate to a rapid intestinal transit time and sometimes follows infective gastroenteritis. A high

intake of sugary drinks or fruit juices can exacerbate this kind of diarrhoea, whereas increasing

dietary fat intake can have a beneficial effect. Drug treatment is unnecessary, although

loperamide can help where something needs to be done, for example in a child who is being

excluded from nursery.

Considerations that would indicate the need for hospital admission include:

signs of dehydration, or uncertainty about state of hydration e.g. an obese child

vomiting of GES, or inability to comply with oral rehydration advice for whatever reason (often poor social circumstances)

persistence or recurrence of diarrhoea

suspected surgical conditions

short history of profuse diarrhoea

pre-existing medical condition which may worsen with diarrhoea e.g. diabetes.


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Constipation and Diarrhoea